WAC 388-538-110   The grievance system for managed care organizations (MCO).  (1) This section contains information about the grievance system for managed care organization (MCO) enrollees, which includes grievances and appeals. See WAC 388-538-111 for information about the grievance system for PCCM enrollees, which includes grievances and appeals.

     (2) An MCO enrollee may voice a grievance or appeal an action by an MCO to the MCO either orally or in writing.

     (3) MCOs must maintain records of grievances and appeals and must review the information as part of the MCO's quality strategy.

     (4) MCOs must provide information describing the MCO's grievance system to all providers and subcontractors.

     (5) Each MCO must have a grievance system in place for enrollees. The system must comply with the requirements of this section and the regulations of the state office of the insurance commissioner (OIC). If a conflict exists between the requirements of this chapter and OIC regulations, the requirements of this chapter take precedence. The MCO grievance system must include all of the following:

     (a) A grievance process for complaints about any matter other than an action, as defined in WAC 388-538-050. See subsection (6) of this section for this process;

     (b) An appeal process for an action, as defined in WAC 388-538-050. See subsection (7) of this section for the standard appeal process and subsection (8) of this section for the expedited appeal process;

     (c) Access to the department's hearing process for actions as defined in WAC 388-538-050. The department's hearing process described in chapter 388-02 WAC applies to this chapter. Where conflicts exist, the requirements in this chapter take precedence. See WAC 388-538-112 for the department's hearing process for MCO enrollees;

     (d) Access to an independent review (IR) as described in RCW 48.43.535, for actions as defined in WAC 388-538-050 (see WAC 388-538-112 for additional information about the IR); and

     (e) Access to the board of appeals (BOA) for actions as defined in WAC 388-538-050 (also see chapter 388-02 WAC and WAC 388-538-112).

     (6) The MCO grievance process:

     (a) Only an enrollee may file a grievance with an MCO; a provider may not file a grievance on behalf of an enrollee.

     (b) To ensure the rights of MCO enrollees are protected, each MCO's grievance process must be approved by the department.

     (c) MCOs must inform enrollees in writing within fifteen days of enrollment about enrollees' rights and how to use the MCO's grievance process, including how to use the department's hearing process. The MCOs must have department approval for all written information the MCO sends to enrollees.

     (d) The MCO must give enrollees any assistance necessary in taking procedural steps for grievances (e.g., interpreter services and toll-free numbers).

     (e) The MCO must acknowledge receipt of each grievance either orally or in writing, and each appeal in writing, within five working days.

     (f) The MCO must ensure that the individuals who make decisions on grievances are individuals who:

     (i) Were not involved in any previous level of review or decision making; and

     (ii) If deciding any of the following, are healthcare professionals who have appropriate clinical expertise in treating the enrollee's condition or disease:

     (A) A grievance regarding denial of an expedited resolution of an appeal; or

     (B) A grievance involving clinical issues.

     (g) The MCO must complete the disposition of a grievance and notice to the affected parties within ninety days of receiving the grievance.

     (7) The MCO appeal process:

     (a) An MCO enrollee, or the enrollee's representative with the enrollee's written consent, may appeal an MCO action.

     (b) To ensure the rights of MCO enrollees are protected, each MCO's appeal process must be approved by the department.

     (c) MCOs must inform enrollees in writing within fifteen days of enrollment about enrollees' rights and how to use the MCO's appeal process and the department's hearing process. The MCOs must have department approval for all written information the MCO sends to enrollees.

     (d) For standard service authorization decisions, an enrollee must file an appeal, either orally or in writing, within ninety calendar days of the date on the MCO's notice of action. This also applies to an enrollee's request for an expedited appeal.

     (e) For appeals for termination, suspension, or reduction of previously authorized services, if the enrollee is requesting continuation of services, the enrollee must file an appeal within ten calendar days of the date of the MCO mailing the notice of action. Otherwise, the time frames in subsection (7)(d) of this section apply.

     (f) The MCO's notice of action must:

     (i) Be in writing;

     (ii) Be in the enrollee's primary language and be easily understood as required in 42 C.F.R. 438.10 (c) and (d);

     (iii) Explain the action the MCO or its contractor has taken or intends to take;

     (iv) Explain the reasons for the action;

     (v) Explain the enrollee's or the enrollee's representative's right to file an MCO appeal;

     (vi) Explain the procedures for exercising the enrollee's rights;

     (vii) Explain the circumstances under which expedited resolution is available and how to request it (also see subsection (8) of this section);

     (viii) Explain the enrollee's right to have benefits continue pending resolution of an appeal, how to request that benefits be continued, and the circumstances under which the enrollee may be required to pay the costs of these services (also see subsection (9) of this section); and

     (ix) Be mailed as expeditiously as the enrollee's health condition requires, and as follows:

     (A) For denial of payment, at the time of any action affecting the claim. This applies only when the client can be held liable for the costs associated with the action.

     (B) For standard service authorization decisions that deny or limit services, not to exceed fourteen calendar days following receipt of the request for service, with a possible extension of up to fourteen additional calendar days if the enrollee or provider requests extension. If the request for extension is granted, the MCO must:

     (I) Give the enrollee written notice of the reason for the decision for the extension and inform the enrollee of the right to file a grievance if the enrollee disagrees with that decision; and

     (II) Issue and carry out the determination as expeditiously as the enrollee's health condition requires and no later than the date the extension expires.

     (C) For termination, suspension, or reduction of previously authorized services, ten days prior to such termination, suspension, or reduction, except if the criteria stated in 42 C.F.R. 431.213 and 431.214 are met. The notice must be mailed by a method which certifies receipt and assures delivery within three calendar days.

     (D) For expedited authorization decisions, in cases where the provider indicates or the MCO determines that following the standard time frame could seriously jeopardize the enrollee's life or health or ability to attain, maintain, or regain maximum function, no later than three calendar days after receipt of the request for service.

     (g) The MCO must give enrollees any assistance necessary in taking procedural steps for an appeal (e.g., interpreter services and toll-free numbers).

     (h) The MCO must acknowledge receipt of each appeal.

     (i) The MCO must ensure that the individuals who make decisions on appeals are individuals who:

     (i) Were not involved in any previous level of review or decision making; and

     (ii) If deciding any of the following, are healthcare professionals who have appropriate clinical expertise in treating the enrollee's condition or disease:

     (A) An appeal of a denial that is based on lack of medical necessity; or

     (B) An appeal that involves clinical issues.

     (j) The process for appeals must:

     (i) Provide that oral inquiries seeking to appeal an action are treated as appeals (to establish the earliest possible filing date for the appeal), and must be confirmed in writing, unless the enrollee or provider requests an expedited resolution. Also see subsection (8) for information on expedited resolutions;

     (ii) Provide the enrollee a reasonable opportunity to present evidence, and allegations of fact or law, in person as well as in writing. The MCO must inform the enrollee of the limited time available for this in the case of expedited resolution;

     (iii) Provide the enrollee and the enrollee's representative opportunity, before and during the appeals process, to examine the enrollee's case file, including medical records, and any other documents and records considered during the appeal process; and

     (iv) Include as parties to the appeal, the enrollee and the enrollee's representative, or the legal representative of the deceased enrollee's estate.

     (k) MCOs must resolve each appeal and provide notice, as expeditiously as the enrollee's health condition requires, within the following time frames:

     (i) For standard resolution of appeals and notice to the affected parties, no longer than forty-five calendar days from the day the MCO receives the appeal. This time frame may not be extended.

     (ii) For expedited resolution of appeals, including notice to the affected parties, no longer than three calendar days after the MCO receives the appeal.

     (iii) For appeals for termination, suspension, or reduction of previously authorized services, no longer than forty-five calendar days from the day the MCO receives the appeal.

     (l) The notice of the resolution of the appeal must:

     (i) Be in writing. For notice of an expedited resolution, the MCO must also make reasonable efforts to provide oral notice (also see subsection (8) of this section).

     (ii) Include the results of the resolution process and the date it was completed.

     (iii) For appeals not resolved wholly in favor of the enrollee:

     (A) Include information on the enrollee's right to request a department hearing and how to do so (also see WAC 388-538-112);

     (B) Include information on the enrollee's right to receive services while the hearing is pending and how to make the request (also see subsection (9) of this section); and

     (C) Inform the enrollee that the enrollee may be held liable for the cost of services received while the hearing is pending, if the hearing decision upholds the MCO's action (also see subsection (10) of this section).

     (m) If an MCO enrollee does not agree with the MCO's resolution of the appeal, the enrollee may file a request for a department hearing within the following time frames (see WAC 388-538-112 for the department's hearing process for MCO enrollees):

     (i) For hearing requests regarding a standard service, within ninety days of the date of the MCO's notice of the resolution of the appeal.

     (ii) For hearing requests regarding termination, suspension, or reduction of a previously authorized service, within ten days of the date on the MCO's notice of the resolution of the appeal.

     (n) The MCO enrollee must exhaust all levels of resolution and appeal within the MCO's grievance system prior to requesting a hearing with the department.

     (8) The MCO expedited appeal process:

     (a) Each MCO must establish and maintain an expedited appeal review process for appeals when the MCO determines (for a request from the enrollee) or the provider indicates (in making the request on the enrollee's behalf or supporting the enrollee's request), that taking the time for a standard resolution could seriously jeopardize the enrollee's life or health or ability to attain, maintain, or regain maximum function.

     (b) When approving an expedited appeal, the MCO will issue a decision as expeditiously as the enrollee's health condition requires, but not later than three business days after receiving the appeal.

     (c) The MCO must ensure that punitive action is not taken against a provider who requests an expedited resolution or supports an enrollee's appeal.

     (d) If the MCO denies a request for expedited resolution of an appeal, it must:

     (i) Transfer the appeal to the time frame for standard resolution; and

     (ii) Make reasonable efforts to give the enrollee prompt oral notice of the denial, and follow up within two calendar days with a written notice.

     (9) Continuation of previously authorized services:

     (a) The MCO must continue the enrollee's services if all of the following apply:

     (i) The enrollee or the provider files the appeal on or before the later of the following:

     (A) Unless the criteria in 42 C.F.R. 431.213 and 431.214 are met, within ten calendar days of the MCO mailing the notice of action, which for actions involving services previously authorized, must be delivered by a method which certifies receipt and assures delivery within three calendar days; or

     (B) The intended effective date of the MCO's proposed action.

     (ii) The appeal involves the termination, suspension, or reduction of a previously authorized course of treatment;

     (iii) The services were ordered by an authorized provider;

     (iv) The original period covered by the original authorization has not expired; and

     (v) The enrollee requests an extension of services.

     (b) If, at the enrollee's request, the MCO continues or reinstates the enrollee's services while the appeal is pending, the services must be continued until one of the following occurs:

     (i) The enrollee withdraws the appeal;

     (ii) Ten calendar days pass after the MCO mails the notice of the resolution of the appeal and the enrollee has not requested a department hearing (with continuation of services until the department hearing decision is reached) within the ten days;

     (iii) Ten calendar days pass after the state office of administrative hearings (OAH) issues a hearing decision adverse to the enrollee and the enrollee has not requested an independent review (IR) within the ten days (see WAC 388-538-112);

     (iv) Ten calendar days pass after the IR mails a decision adverse to the enrollee and the enrollee has not requested a review with the board of appeals within the ten days (see WAC 388-538-112);

     (v) The board of appeals issues a decision adverse to the enrollee (see WAC 388-538-112); or

     (vi) The time period or service limits of a previously authorized service has been met.

     (c) If the final resolution of the appeal upholds the MCO's action, the MCO may recover the amount paid for the services provided to the enrollee while the appeal was pending, to the extent that they were provided solely because of the requirement for continuation of services.

     (10) Effect of reversed resolutions of appeals:

     (a) If the MCO or OAH reverses a decision to deny, limit, or delay services that were not provided while the appeal was pending, the MCO must authorize or provide the disputed services promptly, and as expeditiously as the enrollee's health condition requires.

     (b) If the MCO or OAH reverses a decision to deny authorization of services, and the enrollee received the disputed services while the appeal was pending, the MCO must pay for those services.



[Statutory Authority: RCW 74.08.090 and 74.09.522. 08-15-110, § 388-538-110, filed 7/18/08, effective 8/18/08; 06-03-081, § 388-538-110, filed 1/12/06, effective 2/12/06; 03-18-110, § 388-538-110, filed 9/2/03, effective 10/3/03. Statutory Authority: RCW 74.09.080, 74.08.510, [74.08.]522,74.09.450 , 1115 Waiver, 42 U.S.C. 1396. 02-01-075, § 388-538-110, filed 12/14/01, effective 1/14/02. Statutory Authority: RCW 74.08.090, 74.09.510 and [74.09.]522 and 1115 Federal Waiver, 42 U.S.C. 1396 (a), (e), (p), 42 U.S.C. 1396r-6(b), 42 U.S.C. 1396u-2. 00-04-080, § 388-538-110, filed 2/1/00, effective 3/3/00. Statutory Authority: RCW 74.08.090. 97-04-004, § 388-538-110, filed 1/24/97, effective 2/24/97. Statutory Authority: RCW 74.08.090 and 1995 2nd sp.s. c 18. 95-18-046 (Order 3886), § 388-538-110, filed 8/29/95, effective 9/1/95. Statutory Authority: RCW 74.08.090. 94-04-038 (Order 3701), § 388-538-110, filed 1/26/94, effective 2/26/94; 93-17-039 (Order 3621), § 388-538-110, filed 8/11/93, effective 9/11/93.]